Community Health Worker, Chronic Disease

Lowell General Hospital - Main Campus - Lowell, MA4.0

Full-time
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The Community Health Worker (CHW) delivers culturally-competent services to help patients navigate and access community services, other resources and adopt healthy behaviors. The CHW assists with care coordination tasks such as appointments and/or transportation, patient education and assistance with navigating physical and behavioral health systems, and facilitating communications with providers and other care team members. They will help patients’ self-management by evaluating their needs, assisting with plan development, and working towards patient-centered goals.

Responsibilities:
  • The Community Health Worker will be responsible for helping patients and their families to navigate and access community services, other resources, and adopt healthy behaviors. The CHW works with the Nurse Care Manager to support providers through an integrated approach to disease management and community outreach.
  • CHW activity will promote, maintain, and improve the health of patients and their family through disease education and wellness.
  • Provide social support and informal counseling, advocate for individuals with community health needs.
  • Provide services such as arranging transportation, connections to community programs, setting up Specialist and PCP appointments when needed, and connection to financial support.
  • Responsible for establishing trusting relationships with patients and their families while providing general support and encouragement.
  • Providing ongoing follow-up, basic motivational interviewing and goal setting with patients/families.
  • Follow-up with patients via phone calls, home visits and visits to other settings where patients can be found.
  • Assist patients with completing applications and registration forms both financial and community based.
  • Help patients set personal goals, and attend PCP and specialist appointments.
  • Provide referrals for services to community agencies as appropriate.
  • Transporting patients is strictly prohibited.
  • Work closely with medical provider to help ensure that patients have comprehensive and coordinated care.
  • Work cooperatively with other clinical personnel assigned to the same patient as part of an IDT.
  • Be knowledgeable about community resources appropriate to needs of patients/families.
  • Be responsible for providing consistent communication to the Chronic Disease manager and the registry coordinator to evaluate patient/family status, ensuring that provided information, and reports clearly describe progress.
  • Act as a patient advocate and liaison between the patient/family and community service agencies (i.e. schools, Nursing facilities, hospitals, support groups, etc.).
  • Record patient information in the designated EMR (training provided) and other software no later than 48 hours after patient contact.
  • Attend regular staff and clinical meetings, trainings and other meetings as requested.
  • Manage assigned caseload of patients.
Qualifications:
  • Lives in or familiarity with the target community and feels connected to that community
  • Demonstrates ability to work well with people of various ages, backgrounds, ethnicities, cultures and life experiences
  • Experience working in a multi-cultural setting
  • Experience working in a community-based setting
  • Excellent interpersonal and communication skills telephonically as well as face-to-face
  • Strong customer service skills
  • Detail oriented, with strong organizational skills and multi-tasking abilities
  • Ability to work independently with minimal supervision and as part of a team
  • Knowledge of medical terminology strongly preferred
  • Very strong working knowledge and proficiency with technology and business software (Microsoft Office)
  • Must have reliable transportation for local travel and a valid driver’s license
  • Fluency in second language preferred but not required